What is uhdds guidelines

Kostick nuance. Sanvik nuance. The UHDDS guidelines state all significant procedures are to be reported and a significant procedure is defined as one that is: Surgical in nature, or Carries a procedural risk, or Carries an anesthetic risk, or Requires specialized training It is important to note that the UHDDS is a minimum common core of data on individual hospital discharges and is not intended to serve the entire facility-specific inpatient procedural coded data requirement needs.

Example: Diagnostic excision of liver and pancreas are coded separately. Excision vs. Resection B3. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part.

A total hysterectomy includes the removal of both the uterus and cervix. Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic Inspection and open Resection.

Note 1 Office of Inspector General. References American Hospital Association. AHA Coding Clinic. These data elements and their definitions can be found in the July 31, , Federal Register Vol. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded".

Previous conditions. If the physician has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded.

Some physicians include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy. However, history codes VV19 may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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